Outcome and Recommendations of the North East Consultation Meet on Nutrition held at Shillong, Meghalaya

Recognising the need for upscaling awareness about nutrition and health in the North Eastern Region, the Food and Nutrition Board (FNB) of the Department organised a North East Consultation Meet on Nutrition at Shillong (Meghalaya) on 17-18 February, 2005 with active support from the Government of Meghalaya and UNICEF. More than 75 participants from eight States of the North Eastern namely Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura participated in the Meet. The Secretaries of Social Welfare, Health and Family Welfare and Education were personally invited by the Secretary to participate in the Meet. Except the State Secretary, Department of Social Welfare, Meghalaya, other States were represented by senior officers of the State Government as many of the State Secretaries were attending the Planning Commission meeting in Delhi. Many of the institutions and NGOs actively engaged in child development, nutrition and health in North East also participated in the Meet, like Director and Joint Director (Horticulture), Regional Director, IGNOU, Prof. and Head (Food and Nutrition) Departments of Home Science College, Chief Medical Officers and reputed NGOs.

The programme was inaugurated by the Hon'ble Minister of Social Welfare, Government of Meghalaya, Shri Martle N. Mukhim. Mr. S.K. Tiwari, Additional Chief Secretary, Government of Meghalaya and Mr. Eimar Barr, Deputy Director, UNICEF addressed the participants in the Inaugural Session. A power point presentation on Nutrition Scenario in North East: Call for Urgent Action was made by Smt. Shashi P. Gupta, Technical Adviser (FNB) in the Department. The Secretary (WCD), Smt. Reva Nayyar delivered the Presidential Address in the Inaugural Session and presided over all the sessions of the first day.

The Inaugural Session was followed by State Presentations by senior representatives of all the 8 states of the North East. There was a session on Visualisation in Participatory Planning and Programming involving all the participants of the Meet. Through this interesting practical session, the participants brought out factors contributing to malnutrition and the strategies for eradicating the same.

There were two technical presentations namely "Establishing Nutrition Monitoring, Mapping and Surveillance through ICDS" by Dr. K.V.R. Sarma, Deputy Director, National Institute of Nutrition, Hyderabad and
"Addressing the Widespread Problem of Nutritional anaemia
particularly in adolescent girls" by Dr. Werner Shultink, Chief (Child Development and Nutrition), UNICEF.

The Second day sessions were chaired by Mr. Cecilio Adorna, Country Representative, UNICEF. There was an open discussion on Intersectoral Coordination for Nutrition Promotion facilitated by Smt. Shashi P. Gupta, TA (FNB). The Infant and Young Child Feeding was addressed by Dr. Tarsem Jindal, Prof. of Paediatrics, Breastfeeding Promotion Network of India, New Delhi. Dr. F.U. Ahmed, Director, North East Indira Gandhi Research Institute for Health, Shillong delivered a talk on Addressing Iodine Deficiency Disorders in the Region and Dr. K.V.R. Sarma, Deputy Director, NIN, Hyderabad presented Solutions to the Problem of Vitamin A Deficiency.

There was a Working Group Session to enable active involvement of the participants in providing a framework for developing State Plan of Action on Nutrition.

In the Valedictory Session, the draft "Recommendations of the North East Consultation Meet on Nutrition and the Strategy for Moving Forward" were presented by Smt. Shashi P. Gupta, TA (FNB). Mr. Cecilio Adorna, Country Representative, UNICEF delivered the Valedictory Address and Ms. L. Diengdoh, Director, Deptt. Of Social Welfare, Meghalaya extended a Vote of Thanks.

The two-day North East Consultation Meet was a grand success from all accounts. All the participants attended all the sessions from 9 a.m. to 6.00 p.m. on both the days. It provided an opportunity to review, assess and take stock of nutrition scenario in all the 8 States of North East.

The Secretaries of Ministry of Health and Family Welfare and Department of North East Region, and North Eastern Council have been apprised of nutrition and health situation in the North East. The State Secretaries of Social Welfare of 8 States were provided with the copies of Presentations on Nutrition Scenario in the Nor East and Strategies for Improving Nutrition in the State Secretaries' meet held at New Delhi.

Recommendations

The picture that emerged from several expert presentations both by the Department as well as by eminent experts from other institutions and UNICEF is not very optimistic. The nutrition and health status of children and women in North East is far from satisfactory. For instance, the anaemia levels in women are quite high. The infant mortality rate and under-5 mortality rates in many of the North Eastern States are rather high and most surprisingly the percentage of children vaccinated against all diseases (all the six vaccine preventable diseases in children), is low inspite of high female literacy and matriarchal society of the North East. The North East, therefore, deserves more focus through various nutrition and health interventions of the Government.

The nutritional status of the vulnerable groups is the outcome of complex and interrelated set of factors. Many of these factors relate to health care, hygiene, sanitation, safe drinking water, public health measures etc. Needless to say, if the non-food factors are not taken care of, the supplementary food given to children through ICDS will have no impact. It would be just like a "leaky pot" where food provided through mouth finds the way out through various infections.

The hilly terrain of some of the regions probably makes it difficult for the population to access health and welfare services. Innovative interventions of reaching health care, immunisation, health and nutrition education to the people need to be evolved on priority. Deworming of children and women in areas with high anaemia levels need to be implemented.

Capacity building of field personnel, training institutions and professional organisations in the region also deserve due attention.

Six critical areas were identified for action by the State Governments:

Creating nutritional awareness at different levels utilizing all available channels of communication.

Recommendations of the Regional Consultation Meet on Nutrition at Pune, 19-20 May, 2005

The important Recommendations that emerged from the two-day Regional Consultation Meet on Nutrition for Western Region, covering the States/UTs of Maharashtra, Gujarat, Goa Dadra & Nagar Haveli, Lakshadweep and Daman & Diu, are enumerated here:

Giving high priority to malnutrition control

Nutrition is an input into development. Nutrition was considered critical for human and economic development and its neglect would adversely impact on health, cognitive development of children, productivity of the people, economic growth and slow pace of national development. Nutrition agenda, therefore, needs to be given high priority with greater investment for accelerating human, economic and national development.

A proactive approach for prevention and control of malnutrition was needed.

A revolution in nutrition programming to reach all infants and young children, to address every stage of the life cycle including adolescent girls, to strengthen micronutrient malnutrition control programmes and to monitor behavioural change was required.

State Nutrition Mission

Every State should have a State Nutrition Mission to reduce malnutrition and mortality rates among children and women on the pattern of Maharashtra Nutrition Mission. The Mission should focus on eradication of malnutrition among children and women, motivation and training of the cadre, accountability and flexibility, addressing mother child dyad and empowering community to address the problem of malnutrition on their own. After antenatal registration of the pregnant women, each case should be followed up to ensure child survival as well as optimal infant and young child feeding, immunization etc. Village Health Committees and Panchayati Raj Institutions need to be empowered.

Convergence for synergistic impact

Achieving convergence between Departments implementing developmental programmes was crucial for achieving the synergistic impact. The village level community based micro planning was essential to involve all the available functionaries, numbering about 17-20, in nutrition related services. A resource team was needed to build alliance between Government functionaries and the community so that Assessment, Analysis and Action could become a regular activity. Training institutions like NIPCCD, YASHADA etc could be utilised in micro planning exercise.

The Department of WCD being the nodal Department for implementing the National Nutrition Policy in the country needs to establish stronger linkages with Ministries of Agriculture, Food and Public Distribution, Elementary Education and Literacy, Health & Family Welfare, Information & Broadcasting, Rural and Urban Development, Tribal Affairs to ensure improved food and nutrition security and access to health care. "Community Grain banks" in hunger hot spots to be managed by Gram Sabhas, Women Self Health Groups utilising grain surpluses should also be set up.

Utilising Civil Registration System

Civil Registration System need to be gainfully utilised to provide valuable information on sex ratio, low birth weight of the new borns as was being done in Gujarat. Computerised civil registration at district level interlinked to State level needs to be set up. Audit of all deaths needs to be undertaken.

Urban Malnutrition

The problem of malnutrition was invariably much worse in urban slums than in rural areas. Urban malnutrition, therefore, needs to be addressed more effectively.

Tribal Areas

Special attention was required to address the problem of malnutrition in tribal pockets.

Infant and Young Child Nutrition

National Guidelines on Infant and Young Child Feeding needs to be integrated in the curricula of various training institutions particularly for health and ICDS functionaries. A diploma in Lactation management needs to be instituted. Certification of crèches was necessary to prevent bottle feeding and other harmful practices concerning breastfeeding and complementary feeding.

The ICDS needs to focus on children under three years with due emphasis on the care of the pregnant women, new born care, breastfeeding issues, complementary feeding, hygienic practices for feeding infants and psychosocial stimulation through active feeding. Skill development training of ICDS personnel was an important prerequisite to focus on IYCF issues.

Nutrition and Health Education

A paradigm shift was required from Nutrition and Health Education (NHE) to Nutrition & Health Education and Communication (NHEC) in ICDS. Empowerment of women is an important objective of ICDS but NHEC from an empowerment and behaviour change perspective was one of the weakest links in ICDS.

NHEC has great potential to improve infant and young child feeding practices, improve utilization of services and reduce malnutrition in women and children under-three years. Reorientation of ICDS was needed to make time and resources available for NHEC on a regular and sustained basis, strengthening supervision and monitoring of NHEC. Adequate budget allocation for development, production and dissemination of quality NHEC materials was required. Training in communication and counselling and ensuring outreach of services through home visits also needed strengthening.

NHE should focus on communication for behaviour change, should address family as a whole and not just the women, and should have gender sensitivity built into it.

NHEC has not been given a chance so far. It needs to be taken up as a service and successful experiences giving cost benefit analysis and operations for best practices need to be documented.

Strong networking between Government, Home Science and Medical Colleges, international organisations, private sector etc was needed. The role of media and opinion leaders in NHEC need to be recognized and their representation ensured in various nutrition and capacity building workshops etc so that they serve as the secondary target group and contribute to the communication and advocacy efforts by covering nutrition issues regularly.

Networking with Home Science Faculties and Colleges of Standing

Home Scientists with foods and nutrition specialization were a large untapped human resource that needs to be utilised for improving the nutritional status of families and communities. Premier nutrition teaching institutions need to be identified and regional and zonal centres for nutrition promotion established. These centres should help in building the capacities of extension Home Scientists/Nutritionists in improving the nutrition situation in their state or region. International organisations working in the area of food and nutrition could come forward and support the setting up of such centres by providing necessary infrastructure, expertise and support.

Good nutrition and dietetic practices need and must be a part of daily life if people are to be healthy. It was, therefore, important that those who do not pursue a professional career in food and nutrition must have "NUTRITION LITERACY" so they do not fall a prey to wrong mass media advertisements. A compulsory course on "NUTRITION LITERACY" needs to be included by UGC in all academic courses for all students.

It is high time to work towards "NUTRITION REVOLUTION" in the country.

Improving status of Training Centres.

The present status of Middle Level Training Centres (MLTC) deserved strengthening in terms of honorarium, career management, motivation and recognition to attract properly qualified trainers and Principals on a sustainable basis (currently the Principal was drawing only Rs. 4900/- and Trainer Rs. 4500/- per month)

Involvement of Women's Technical Education and Research Institutes

The area of work of Women's Technical Education and Research Institutes of Ministry of HRD has been currently extended to cover BPL population of urban areas including physically and mentally challenged people although it is basically a rural based project. There are 450 community polytechnics in the country (Maharashtra having 37 each) with a fund allocation of Rs. 7.00 lakhs. Networking with community polytechnic of India would help reach nutrition and health information to villages. Rural Diet Counselling Centres could be started in each extension centres of these Institutes.

Formation of Nutrition/Diet Council of India

A Nutrition or Diet Council like the Medical Council of India is needed to promote the cause of nutrition and dietetics in the country. Quality management of various courses and training programmes in this field, employment potential, recruitment details for this important paramedical course, associated matters like nutrition/health tourism and hospitality industry, intellectual property rights, nutraceuticals etc factors could be looked into by such a Council. All these are needed for improving the quality of teaching in this area and its utilization in the overall nutrition and health delivery system of the country.

Micronutrient Malnutrition Control

A holistic approach for addressing the widespread problem of micronutrient malnutrition was required. The prevalence of vitamin A deficiency (VAD) being still of public health significance required concerted efforts for its elimination. The prevalence of VAD was high in 3-6 year age group also besides 1-3 years and hence it was necessary that Vitamin A Supplementation Programme was extended to children upto the age of six years, as was being done in other South East Asian Countries also.

Nutritional Anaemia continued to be a cause of concern as its prevalence was above 70% in high risk groups namely infants and young children, adolescent girls, pregnant and lactating women. Iron and folic acid supplementation for adolescent girls needs to be undertaken on a national scale on top priority. Similarly, IFA supplementation for infants who were not covered so far under the programme deserved top priority.

The Ministry of Consumer Affairs, Food and Public Distribution need to make adequately iodized salt available through the Targetted Public Distribution System. Supplementary Feeding Programmes under ICDS and Mid Day Meal to use only adequately iodized salt.

Fortification of common foods is one of the important strategies for addressing the problem of micronutrient deficiencies in a short time in cost effective manner. Fortification of wheat flour with iron and folic acid and double fortification of salt with both iron and iodine need to be taken on priority.

The supply of wheat through various Government schemes, PDS needs to be changed to fortified wheat flour. States with some reservations could initiate a pilot project.

The Integrated Food Law being enacted may include micronutrient fortification of foods as per the CODEX guidelines.

The Information, Education and Communication (IEC) on wheat flour fortification was also required to create awareness among the people. States could examine accessing funds for Staple Food Fortification Programme from GAIN (Global Alliance for Improving Nutrition) through their State Nutrition Mission/Fortification alliance.

Recommendations of the Regional Consultation Meet on Nutrition held at Bhubaneswar on 18-19 July, 2005

The important Recommendations that emerged from the two-day Regional Consultation Meet on Nutrition for Eastern Region, covering the States of Bihar, Jharkhand, Orissa and West Bengal, are enumerated here:

Malnutrition is a drain on Economy and a silent emergency requiring urgent multipronged action

Malnutrition is a drain on economy and adversely affects national development. Thus, malnutrition was a Silent Emergency and required innovative measures for its prevention and control. A multipronged action involving all developmental sectors was required urgently to address the problem of malnutrition in a time bound manner.

The action and progress to be monitored in months and not years.

Urban malnutrition was as bad as rural picture if not worse, and deserved due emphasis.

Panchayati Raj Institutions for convergence and effective delivery of services at periphery

Out of the six services provided through ICDS, three and a half services concerned health sector. Convergence of services was important and the Panchayati Raj Institutions could be utilized to achieve convergence. Interface between Government and PRI system needs to crystallize.

Food and Nutrition Mission at the State Level

State Level Coordination Mechanism is essential for policy initiatives and greater synergy between various programmes. A centrally sponsored Food and Nutrition Mission at State level could be the best option to address the problem of malnutrition in a mission mode.

Better Linkages between ICDS and Department of Elementary Education and Literacy

"Balwarg" comprising of 3 - 6 year old children need preschool education as well as supplementary feeding and micronutrient supplements. Such children covered under "Sarva Shiksha Abhiyan" should be provided quality preschool education and nutrition through convergence between MID Day Meal and ICDS as Education has a separate teacher for "Balwarg".

The existing training institutions under Education like Block Resource Centres (BRCs), Cluster Resource Centres (CRCs) (for a group of villages in good middle school) and DIETs should be utilized for training ICDS personnel too. One training centre could take care of two ICDS projects.

Joint Committee of Education and ICDS should look after both programmes for better convergence.

Nutrition Education should become an important service under ICDS.

Syllabi of all formal and non-formal educational systems should have basic nutrition information. The syllabi should be reviewed and nutrition content incorporated utilizing the expertise of FNB and NIN.

School children can prove to be the best change agents. NIN has converted FAO "Feeding Minds Fighting Hunger" publication to suit Indian system. The Indian module on Feeding Minds Fighting Hunger should be incorporated in primary, secondary and senior secondary school curricula.

Effective positioning of Infant and young child Feeding in ICDS, RCH, NRHM etc.

Optimal breastfeeding i.e., early initiation, exclusive breastfeeding for the first six months and continued breastfeeding upto two years and beyond alongwith complementary feeding introduced at six months of age, was considered critical for child survival, development and health. Exclusive breastfeeding for first six months and continued breastfeeding for another six months along with adequate complementary feeding has shown to reduce infant mortality rate by 16% (Lancet 2003).

Priority to infant and young child feeding has to be reflected in national/state/local plan resources and goals.

Effective positioning of infant and young child feeding in ICDS, Reproductive and Child Health, National Rural Health Mission and others - focusing on best possible start to life, survival, growth and development, maternity protection and family support is required.

Adopting / translating National Guidelines on Infant and Young Child Feeding, integrating these in the training curricula under ICDS, Reproductive and Child Health, Panchayati Raj Institution and Rural Development needs to be undertaken on priority.

ICDS monitoring to include indicators on early initiation of breastfeeding, exclusive breastfeeding for first six months, complementary feeding with home based foods from six months along with continued breastfeeding up to two years or beyond.

Reposition ICDS with a focus on under twos. Deliver IYCF counselling as a service in ICDS.

BPNI's network in States and Districts to be utilized for skill development training, capacity building and awareness generation on IYCF.

Promoting production of low cost processed and fortified complementary foods for infants and young children at District, Block and Village levels

Production of low cost processed and fortified blended foods for ICDS beneficiaries utilizing Self Help Women Groups needs to be promoted at district and block levels.

Self Help Women Groups to be the owners of such production units (2 MT capacity/day) with one time financial assistance as has been done in Orissa.

Public - Private partnership for reaching "Sattu" like instant infant mixes at village shops should also be explored.

Addressing critical stages of life cycle adopting life cycle approach

Focus on prenatal care and counselling, under threes, pregnant and lactating mothers and adolescent girls.

Emphasis on early action and preventive approach is required.

Joint Training and Supervision of ICDS and Health personnel for synergetic impact

Joint training of ICDS and health personnel is essential.

Using a common mother-child growth and development card by RCH and ICDS and an entitlement card for unreached population would be desirable.

Monitoring of performance under ICDS to be based on "Outcome indicators" and not "Process indicators" alone

Monitoring of ICDS through Monthly/Quaterly Progress Reports to be based on "Outcome" indicators like improvement in nutritional status of the children rather than "process" indicators like receiving supplementary food, preschool education etc.

Ensuring 100 % weighing efficiency in ICDS

Weighing efficiency was reported to be directly proportional to reduction in malnutrition levels.

Universalisation of ICDS should also mean 100 % registration of all children under three years, all under threes to be weighed and all under three families to be provided with mother child card.

Addressing micronutrient malnutrition in a holistic manner

Micronutrient malnutrition control requires concerted action on all the five major strategies viz. Dietary Diversification, Supplementation, Food Fortification, Horticultural Interventions and Public Health Measures.

Ensuring universal coverage under Iron and folic Acid supplementation programme and extending the anaemia control programme to cover infants and adolescent girls needs to be taken up on priority.

ICDS workers could identify moderate and severe anaemia through pallor of mucosal membranes and take remedial measures.

Importance of iodine in brain development to be emphasized in communication efforts.

Vitamin A supplementation coverage should be universalised for children under 3 years and all efforts made to cover children up to 6 years. Household and community production and consumption of red, yellow and green coloured fruits and vegetables besides milk and eggs needs to be promoted.

Multipronged strategies with due focus on fortification is required for addressing micronutrient malnutrition.

Micronutrient malnutrition has been effectively addressed through fortification in West and also in some South American and African countries. Fortified wheat flour in Darjeeling district of West Bengal demonstrated a significant reduction in anaemia (15 - 16 % in adolescent girls) in 18 months period.

Supplementary foods for ICDS beneficiaries and Mid Day Meals for primary school children should be fortified with essential micronutrients.

Iodised salt and fortified supplementary foods should be made available to people through fair price shops.

Fortification of cereals with iron and folic acid, salt with iron and iodine needs to be adopted on priority.

Vigorous Awareness Campaign on Nutrition

The link between nutrition education and health needs to be emphasized. Awareness on consequences of malnutrition on physical and mental growth, school performance, productivity and economic growth needs to be generated.

Nutrition education should address family as a whole and not just the women. Nutrition education should focus on communication for behavioural change.

Advocacy and sensitisation of policy makers and Parliamentarians should be undertaken to create "Administrative" and "Political" will.

Networking with professional institutions like Food and Nutrition departments of Home Science Colleges, Medical Colleges and NGOs was needed to extend the coverage under nutrition education.

Electronic media to be involved in Advocacy and Behavioural Change Communication.

All commercial advertisements need to be censored and celebrities need to dissociate themselves from the same.

Achieving Convergence between ICDS and RCH

Observe Nutrition and Health days in AWCs to increase outreach coverage with focus on ANC, weighment, immunisation and micronutrient supplementation.